Neuro-Oncology
Questions discussed in this category
If further resection is possible, would you recommend adjuvant radiation?
Would you consider definitive radiation alone?
Would you recommend convent...
For example, a patient with 100 WBCs in CSF with a peripheral WBC 43k/mm3 due to AML.
Specifically, headaches thought not to be related to increased ICP.
E.g., patients with small CNS mets without vasogenic edema or symptoms. Epidural disease without epidural spinal cord compression or asymptomatic low-...
For a patient with prior WBRT + SRS, or SRS + SRS to the same area, who has a convincing in field recurrence, would you ever consider a third course o...
Guidelines do not provide strong guidance on who will benefit from temozolomide vs PCV or when to consider re-challenging with temozolomide.
What dose/fractionation do you prefer? What is the maximum dose that you will allow to the optic nerve and chiasm?
I have seen targeted therapies used (and studied) more often in the recurrent setting. However, there may also be some rationale for trying BRAF/MEK E...
If so, how long do you continue medication and when do you discontinue? Does treatment with surgical resection versus radiation alone change your mana...
Is there a dose response between 4500 and 5040 cGy?
How do factors such as the stability of the bleed, tumor histology, and patient condition influence your decision?
When would you recommend chemotherapy alone, radiation alone, and combined chemoradiotherapy? When treating with RT, what volumes and doses do you use...
Guidelines support standard fractionation when tumors are large or have brainstem compression but what would indications be for moderate hypofractiona...
What is ideal timing between radiation and surgery? Would you recommend implant first and then radiosurgery? Any additional constraints to the acousti...
Would you offer radiation and chemotherapy, vorasidenib, or observation?
Are there situations in which one imaging modality has clear advantages over the other?
Would you continue it until progression of disease? Or would you switch immediately to next line systemic therapy?
Found small reports using SRS or fractionated SRS, but not feeling comfortable with this approach due to limited data. Would you consider surgery + co...
Do you consider hypofractionation rather than a volume staged approach?
I have always used the RTOG standard 2 cm margins off the T2 Flair to 46 Gy and 2 cm off the T1post for the 14 Gy boost. However, recently I have hear...
Are there specific safety concerns or long-term risks that should be accounted for when considering drug holidays or overall treatment duration?
How will you implement response assessments in patients starting tovorafenib given potential for pseudoprogression vs true progression?
Is it merely another option to try or will it become the standard choice for patients experiencing relapsed/refractory disease?
Is there any data to suggest higher risk of malignant transformation with hypofractionation? Does concurrent Temozolomide change your approach?
Are GTV, CTV, PTV expansions adopted from pediatric studies? Given our ability to treat the craniospinal axis with accuracy, what would the "mode...
Why does this differ when treating extracranial sites (lung, pelvis) where we hold bevacizumab prior to RT?
Tumor measures 4 cm after STR. Is NF1 a contraindication for adjuvant RT?
NRG-CC001 excluded a patient like this, but it seems that if the lesion in the HA region is treated, it would be reasonable.
How to treat Radiation Induced Sarcoma (RIS) of the spinal cord after 40 years of postoperative radiation therapy to lower dorsal/upper lumbar ependym...
Do you treat this similarly to IDH-Wildtype GBM with the STUPP regimen? Is there any role of less-intensive paradigms, such as 59.4 Gy/33 fx?
Does the volume of or recent progression of other non-spine disease influence your patient selection? Does the patient's performance status, eligibili...
Would you treat just the gross tumor at recurrence or the entire initial operative bed? Do your volumes and dose differ from those treated adjuvantly ...
Are there additional studies that could be done to assist with management decisions?
Is there a role for adjuvant chemotherapy or radiation?
Would you consider radiation following surgical resection of an intramedullary benign nerve sheath tumor with a small amount of residual tumor (9 mm) ...
Female in her 30s, L5-S2 tumor volume, treated in 2020. So far, L-S MRI q6 month shows no change in residual tumor.
In light of the recent consensus contouring guidelines (Soliman et al., IJROBP 2017): 1) Are you routinely expanding along the dura up to 5-10 mm...
Would you consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...
Do you recommend adjuvant chemotherapy after radiation treatment?
With the recent publication in IJROBP showing a greater than 50% response rate, have you started integrating this into your practice?
Do you ever allow patients to receive a couple of cycles of systemic therapy first if there is high burden of disease? What is the maximum time after ...
Does the MGMT status change your decision-making? Should we be routinely testing MGMT for elderly patients?
What is the harm of waiting for another recurrence after a second GTR to delay the toxicity of radiation and chemotherapy? The patient is a woman <...
If so, how many days before and after? Does this change if delivering SRS?
In a patient with metastatic cancer to the lumbar spine and epidural disease on CT who presents back pain and leg weakness:
Is a whole spine MRI in...
Particularly, would you have concerns about OAR constraints or cumulative dose? Patient has excellent performance status and no neuro deficits post op...
Does your constraint differ based on region of the spinal cord?
Do all patients with brain metastases get started on anticonvulsants?
Do you decide based on extent of edema, tumor size, or something else?&nb...
What would be your preferred treatment technique and dose/fractionation?
What workup do you typically recommend?
How do you choose between Avastin, hyperbaric O2 and other therapies?
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
Patient with circumferential thoracic spine tumor on imaging, with appearance of hemangioma. Surgical pathology demonstrated glomus tumor.
Woul...
If so, have you noticed differences in cognitive function post WBRT?
If so - how long?
Would you dose escalate areas of regrowth or boost the entire cavity?
Is there diminished radiotherapy efficacy in tumor control after certain timeframe has passed for malignant meningiomas with no signs of recurrent dis...
Do you treat on the same days or sequentially? Any unique considerations regarding dose or planning?
What is your GTV, CTV and PTV? If giving 30 Gy in 10 fx, does the contour need to extend all the way to the cut in the skull on both sides (is there a...
Does fractionation (or location) influence this decision? What is your preferred steroid dose?
> 50-year-old woman with a pilocytic astrocytoma of the 4th ventricle (biopsy only). Caris shows BRAF intact and deleted CDKN2A/B.
For example a 1 or 2 mm brain metastasis? Would you consider waiting for these to enlarge slightly for reasons such as more certainty they are real, l...
Do you routinely recommend TTF in the adjuvant setting for patients with glioblastoma?
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
With molecular diagnosis taking several weeks to return for some institutions, how do you handle variations in dosing and contouring between different...
Adult patient with suprasellar tumor, found to be AT/RT and unable to undergo GTR given encasement of optic structures.
Do you have a size cut-off in cases where OAR tolerances are not otherwise exceeded?
With targeted therapies available, is there a utility for post-op SRS to the resection cavity?
Would you offer adjuvant RT for subtotal resection of a parietal lobe hemangiopericytoma? How would histologic grade affect your decision making?
What do you utilize for patient immobilization and what are your PTV margins? What MRI sequences do you favor for target delineation?
Would you favor observation or adjuvant radiation? If so, what dose/fractionation would you consider?
Molecular findings that indicate a more aggressive WHO grade 2 meningioma would certainly support recommendations for adjuvant RT after GTR, but if th...
Do you treat this as a higher grade tumor or alter your adjuvant recommendations?
Is it necessary to repeat MRI a certain amount of time after surgical resection prior to starting radiation?
If a patient has a metastatic lesion in close proximity to one hippocampus, would you offer sparing of the contralateral hippocampus? Do your dose con...
What factors influence your choice of SRS vs more fractionated regimens?
In patients with contraindications to receiving an MRI scan, are other imaging modalities sufficient to treat patients with SRS?
Is your approach different than that to a primary essential tremor?
History of 4th ventricle choroid plexus papilloma s/p GTR, now with recurrent disease in the 4th ventricle and the left lateral ventricle (7 nodules i...
Several articles report results with 0.5 -1 cm margins, and have suggested that with improved imaging and treatment planning, smaller margins such as ...
How does 1p/19q co-deletion and IDH mutation status influence your decision?
Is there a certain amount of time that you prefer to have elapsed after the last infusion before delivering SRS? Do you avoid all subsequent Trastuzum...
How long would you wait to see if the AVM obliterates? How would size or proximity to critical structures affect your decision i.e., would you choose ...
Do you have a number/volume threshold for SRS vs WBRT?
Is there sufficient data to justify the routine use of GammaTile in the treatment of primary CNS malignancy or brain metastases?
When do you consider observation?
Would you consider empiric SRS if biopsy/resection is not feasible?
When would you consider liquid biopsy?
If not, what interval between the patient's last RT and IT chemo would you prefer?
What is your preferred dose/fractionation following a previous course of radiotherapy?
In a large unresectable grade 2 astrocytoma of the temporal lobe, what dose and GTV margin should be used?
With the recent WHO classification redefining IDHwt tumors as glioblastoma, more patients have imaging features that are historically consistent with ...
VS schwannoma size 16mm
Patient received FSRT 25 Gy in 5 fx more than 4 years ago
What would be your next treatment for a young adult patient with medulloblastoma refractory to repeat resection, craniospinal irradiation, and initial...
Assuming in-field recurrence.
I have seen small amounts of evidence for V4<20cc and V14<7cc, but overall it seems like there is little published on this issue.
Would your recommendations change based on patient age (pediatric vs adult)?
Louis et al., PMID 34185076
If not, then what is your preferred treatment and would you integrate SRS into it?
Does it matter if the patient has a history of WBRT?
Does the specific chemotherapy agent (MTX vs Topotecan vs Triple Intrathecal) change your recomm...
Do you ever add prophylactic Keppra (levetiracetam) for glioblastoma patients without a seizure history based on data such as this study (nature.com) ...
How close can a metastasis be to the PRV05 and still make hippocampal sparing feasible? Do you ever reduce the margin on the hippocampi to 3 mm, if yo...
How often are you scanning the brain and what is your trigger to treat?
Do you treat on consecutive days or more protracted interfraction intervals? Does tumor type (benign vs malignant) or size influence your choice?
Would superficial dehiscence along the incision delay you starting radiation?
Does your surveillance schedule change dependent upon delivery of SRS vs conventional-fractionated RT?
Does the elapsed time from prior chemoradiotherapy impact your selection of dose/target volumes?
If so, what percent likelihood do you quote patients for this risk with SRS, SRT and fully fractionated therapy?
Do you routinely discontinue the device or continue if they are otherwise tolerating the treatment well?
What is the diagnostic yield and complication rate in your experience?
Assuming no overlap with prior RT doses, would a history of necrosis cause you to hypofractionate rather than deliver single fraction SRS?
Is it better to sacrifice target coverage (reducing volume receiving 95-100% dose) or change to fSRS in order to meet cord constraints without having ...
Should it include the entire brain (normal brain + target) or just the normal brain (brain - target)? How does the V10 or V12 constraint change ...
What maximum dose do you allow to “connect” adjacent metastatic lesions receiving SRS/SRT?
What is this value for one-, three-, and five-...
NCCN lists PCV as category 1 (and now with analysis in Abstract 2002 from ASCO 2019 showing benefit in IDH mutated), and temozolomide as 2B, yet temoz...
If not, how should you select those cases that should be referred?
For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...
Is there a role for SRS/fSRS?
When would you add steroids or consider Avastin?
Is there a role for SRS in this situation?
What would be your preferred technique and dose/fractionation?
Is there evidence that supports/refutes the safety of concurrent use?
For stroke-like migraine attacks after radiation therapy (SMART syndrome), does your management of these patient's change with recurrent episodes? How...
Can intrathecal methotrexate be continued with close neurologic observation vs switch in treatment now due to findings?
If so, when do you consider this?
Do you biopsy immediately, stop treatment, biopsy at a later time, or depend solely on the data you already have?
Is there any additional benefit to radiation in addition to steroids in a patient who is not a surgical candidate?
Are there specific dose constraints for the brainstem that you use?
Would extent of surgical resection matter?
Do these patients need CSI (like Pineoblastoma), just local radiation, or something in-between (say whole ...
Do you uniformly recommend adjuvant treatment or reserve SRS for a subtotal resection and/or recurrent disease?
Do you have a volume cutoff in which you would prefer a more fractionated approach?
Additionally, do you routinely add concurrent temozolomid...
They are known to have worse prognosis. For an adult with supratentorial G2 ependymomas s/p GTR, radiation is generally not indicated. Does this chang...
How does grade affect your decision-making? If adjuvant radiation is indicated, should the initial extent of disease be included or only the post-oper...
Do you prefer WBRT, IT chemo or targeted systemic therapy and what is your preference on the sequence of therapies?
Has the recently published interim analysis of the CATNON trial altered your utilization of temozolomide?Does IDH status change your treatment approac...
Do you consider the small, but statistically significant, improvement in OS to outweigh the side effects of treatment?
Do you decrease total dose, increase the number of fractions, or both? What factors, in addition to size and location, do you consider?
Under what circumstances would you discontinue or alter therapy?
Length of temozolomide course when given with adjuvant radiotherapy
What factors play into your decision whether to re-treat the brain with craniospinal radiotherapy vs irradiation of the spine only vs other measures (...
What are your dose constraints for the cord in these situations?
Do you make any modifications to your dose or treatment technique?
Do you typically use the immediate post-op MRI scans or do you routinely obtain updated MR imaging at the time of CT sim?
If so, at which intervals do you re-image?
If fractionating one metastasis over 3 or 5 fractions, would you also treat a small metastasis with the same number of fractions or would you give sin...
E.g. The case in question is for a patient planned for thoracic RT for LS-SCLC. Any medications that may help or just give much bigger expansions to c...
When do you favor RT? What is your preferred dose/fractionation?
How does length of time from prior chemoradiotherapy influence your management?
There does not appear to be any guidance from the most recent published protocols on this topic. For individuals with dementia, recommendations call f...
Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?
Would you deliberately spare the area of necrosis in your WBRT treatment plan?
What techniques do you employ for motion management?
Do you give SRS/fSRS or would you ever elect to closely observe if the patient is receiving immunotherapy/targeted agents?
I find postop that these l...
How does the presence of prior WBRT alter your treatment plan?
In a palliative setting, how long would you wait to initiate WBRT?
If progression is proven by imaging modality (MRI spectroscopy, perfusion and PET/CT), is there evidence for retreatment with a second course of SRS?&...
Would you ever de-escalate your prescription dose in order to reduce cochlear dose when treating younger patients with intact hearing?
Do you have a specific pituitary dose threshold?
Do you typically refer prior to or following radiotherapy?
For example, would you treat more distally along the nerve or the involved branch if symptoms are localized?
If a WHO II glioma was treated with RT and recurs and is now a WHO III glioma would you retreat with radiation? What would be your target volume...
For example, meningiomas or pituitary adenomas?
The recent Roa trial (JCO 9/21/15) found that 25Gy/5fx was non-inferior to 40Gy/5fx in terms of OS, PFS, and QOL. Is 25Gy in 5 daily fractio...
Do you ever boost the areas of residual tumor or do you treat the cavity and tumor as a homogeneous target volume?
Is there a role for neoadjuvant radiotherapy prior to attempted embolization or resection? Do you routinely electively cover the location of prior sur...
When would you offer hypofractionated radiotherapy?
What dose/targets do you typically use?
What dose/fractionation do you prefer?
What dose/fractionation would you use for treatment of a tumor without a biopsy?
Utility of maintenance chemotherapy per ACNS0831 in patients with anaplastic ependymoma
Do you routinely cover the surgical tracts?
When, if ever, would you consider up-front SRS for first line therapy?
Given the proximity of the optic chasm and risk of compromised hemianopsia, the lack of adequate central vision adds another layer of risk.
What factors do you consider when offering retreatment? If you use repeat-SRS, what dose and fractionation?
In which situations would you consider 37.5 Gy / 15 fx or 20 Gy / 5 fx over 30 Gy / 10 fx?
When do you decrease your SRS dose or consider fractionated SRS regimens?
The margins vary widely in the literature (Roa et al utilized edema +2cm while Perry et al utilized T1+C +1.5cm for CTV).
Given the poor prognosis of molecular subtype, do you offer a more aggressive treatment regimen than for other molecular subtypes of low-grade glioma?...
Discuss the role of mAb in DIPG.
In a patient who received full dose to the spinal cord 10+ years prior, would SBRT be appropriate salvage therapy or is hyperfractionation prefer...
Would you consider this if the patient does not appear to have hippocampal involvement? Or is the risk of subsequently developing hippocampal metastas...
What dose/volumes would you recommend for a previously radiated tumor not amenable to surgical resection?
When would you elect for surgery vs radiotherapy (SRS)?
When would you offer re-irradiation in the setting of prior RT and tumors not amenable to gross total resection?
Discussion of treatment options for midline low-grade glioma causing life-altering symptoms in a pregnant patient to avoid teratogenicity.
When would you recommend SRS vs WBRT?
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
What is your recommended dose/volume for large tumors s/p limited resection? What dose constraints do you use for the visual pathways?
My understanding is that this risk is exceedingly rare even with treatment in and around the stalk and hypothalamus.
If normal tissue constraints can be met, should most patients (including ones with secretory tumors) be treated with radiosurgery and/or hypofractiona...
Is this one of the factors you use when deciding between repeat SRS vs. whole brain radiation therapy for distant brain relapses?
What dose fractionation and volume do you use? What factors influence your decision?
Is there a threshold for WBC or platelets below which you would hold RT?
When would you request a biopsy of a meningioma?
Do you extrapolate from the pediatric protocols (smaller margins) or use larger margins similar to treatment of adult high grade gliomas?
If the patient has an asymptomatic local recurrence of a CNS ependymoma previously treated with a full course of radiation, would you re-treat with ra...
Assuming the patient is not a candidate for SRS
When do you consider re-irradiation?
Would you avoid WBRT or PCI if otherwise indicated?
Do you offer WBRT or SRS? If you prefer SRS, do you follow up with WBRT?
Temodar can sometimes take 2-3 weeks to arrive after prior approval. Would you start radiotherapy without Temodar or wait for it to arrive and begin c...
What is your preferred dose/fractionation? What constraints do you utilize for the brainstem and cord?
Do you include the entire hemorrhage volume in your target?
What would be your preferred dose and treatment volume?
How do you manage these?
If so, how long should the medication be stopped prior to SRS?
Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...
Specifically, how do you explain potential cognitive decline in a way that explains what changes they can expect in their daily lives?
If so, what would be your recommended technique/dose?
Is there any role for SRS/FSRT?
Will this disappear over time on its own or should I be concerned that the necrosis will worsen over time, and repeat MRI more frequently?
Do you utilize fMRI or other advanced sequences (DTI, etc) in the planning process?
How do these change in the setting of previous radiotherapy/radiosurgery?
What factors do you consider? Size, symptoms, etc?
Do you have any specific concerns for patients with implanted intracranial devices?
Is there a role for aggressive surgical resection if the lesions are reasonably resectable or do you prefer biopsy followed by chemoradiotherapy?
When do you decide to fractionate?
What dose/fractionation do you prefer for small vs large metastases?
How should they be prioritized? V10, V12, mean brain dose, prior WB radiation? To what extent should tumor coverage, conformality and homogeneity be c...
Is there a size or number of metastasis cut-off where you would consider SRS vs. WBRT?
Do you fractionate? Do you look at composite doses and/or apply any constraints given the limited data?
Can a second course of SRS be completed? If so, what dose do you recommend?
Is SRS reasonable if there is no evidence of more diffuse disease?
Do molecular factors (1p/19q, IDH status) influence your choice of dose/volumes?
Do you insist that the staples are removed prior to sim or do you perform density overrides in the treatment planning system?
What factors influence your decision?
Would the results effect your decision to offer PCI?
There are data for improved outcomes for inhomogeneous dose distribution in patients with intact brain tumors (Lucia et al, Radiother Oncol 2018), but...
Dependent upon histology, when would you offer RT to an asymptomatic patient who refuses consideration of any future surgical intervention?
For a patient in the second trimester who wants to continue with the pregnancy, would you consider this? If so, what extra precautions would you take?...
What is your preferred dose/fractionation?
Do you prefer using MR perfusion, MR spectroscopy or brain PET?
If you use PRVs, how do you adjust their constraints relative to their respective OAR constraint (e.g. do you allow a greater percentage or absolute d...
Do you prefer to underdose the tumor to meet critical structure constraints such as the optic chiasm? Or to you opt to aggressively treat the tumor an...
Is there an optimal time to give SRS to brain metastases for patients receiving ipilimumab and nivolumab?
How do you delineate your treatment volumes? Do you modify your post-treatment surveillance of these patients?
Do you modify your dose/fractionation if the target volume abuts surgically implanted hardware?
Would you modify your dose/fractionation dependent upon intracranial control of the primary tumor?
It becomes challenging to keep track of different metastases, especially for patients who have undergone one or more prior SRS treatments.
Any special considerations with RT dose or fields?
Would this be any different for whole brain radiotherapy?
Despite some supportive data, it seems few institutions use these routinely. What do you view as the barriers in their utilization?
Would you offer 3-5 fractions for larger lesions instead or would you favor more traditional standard fractionation regimens?
If so, do you have specific dose constraints you find reasonably achievable given the difficulties in achieving some of the very low dose goals noted ...
Do you routinely pause systemic therapy when administering SRS? Which agents do you view as relative or absolute contraindications with SRS?
Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?
Would you include the entire original surgical cavity or only the region of recurrent disease?
Do you make any modifications to your treatment field or dose?
If a patient has simple bony metastases and no neurologic compromise what are your criteria for recommending that a patient wear a collar for c-spine ...
Provided patient is tolerating treatment well.
Does your recommendation change if the patient has received prior standard fractionation radiotherapy vs SRS?
Would you ever defer radiation in patients with primary brain tumors or would you manage these patients similarly to non-MS patients? How do you ...
In our clinical experience, we have used the treatment planning system's auto-match method, and then manually fine tune adjustments checking skull, IA...
How often do you obtain routine imaging if there has been no documented growth after 5 years?
If imaging is negative for other sites of dissemination within the CSF, do you treat with craniospinal RT or use more localized fields?
Would you delay/defer adjuvant radiation and/or temozolomide until completion of IV antibiotics? Would you still treat with a significant skull defect...
For a lesion that appears radiographically consistent with a high grade glioma, would you treat empirically if there is hesitancy to perform a high ri...
The small series by Lowell et al (IJROBP 2011) suggests significant toxicity risks following SRS.
What is your cavity size/volume cutoff in selecting hypofractionated SRT over SRS?
For treatment of multiple brain metastases, the V12 can often exceed the traditional dose constraint of 10 cc, especially as the number of lesions bei...
Are there treatment planning considerations that are different for a large cystic lesion as compared to a solid metastasis?
For patients with eGFR of < 30, there is a risk of irreversible nephrogenic systemic fibrosis with gadolinium. Would you prefer whole brain for the...
Do you modify your dose/fractionation depending on the amount of prior intrathecal therapy?
Do you routinely offer re-irradiation? If so, what is your preferred dose and technique?
Would you start radiation without temodar if there is a delay in temodar rx?
What is the role of the 3T MRI mprage sequence? Is there any literature to support a certain approach?
If choosing systemic therapy, do you prefer bevacizumab with or without irinotecan? Have you used anti-PD1 agents (e.g. nivolumab) off label?
Would you feel comfortable treating with palliative radiation without neurosurgical assessment? Are these patients at increased risk for neurolog...
Does it matter whether the intracranial lesions have been treated with whole brain or SRS/SRT?
There are solid data from Emory, Korea and others suggesting that is as effective as single fraction SRS but has less complications.
Would you insist that they shave or cut the beard? Is there a way to make the simulation reproducible without removing the beard?
Does the time interval to progression, current use of immunotherapy, KPS, etc influence your decision?
The plans appear so much more conformal. If not, what is the rationale?
If utilizing conventionally fractionated radiation, do you cover just the gross disease or do you cover the preoperative tumor volume? What if you are...
Is it reasonable to go with surveillance instead and keep radiation as a salvage option?
Do you approach it similar to a de novo GBM? Would you be more inclined to offer hypofractionated radiation given the poorer prognosis?
What has been your preferred management?
When can you feel confident that the growth is from tumor vs. radionecrosis?
To what degree, if any, is a neurosurgeon involved in the planning of SRS for brain metastases?
The 2014 "Choosing Wisely" list, released this past September, includes the assertion that we should not "routinely add adjuvant whole brain radiation...
And at what intervals? The published trials/RTOG call for q3 month MRI follow-up. Is this appropriate outside a clinical trial setting?
In particular, for patients without clinical symptoms, would you image the spine based on any histologic, molecular, or other risk factors?
One study comparing these techniques (https://www.ncbi.nlm.nih.gov/pubmed/12873685) showed 75% hearing preservation in the single fraction group ...
I've seen 15Gy quoted as an effective GK dose, and a variety of LINAC doses in the literature.
If there was true residual disease, do you offer whole brain RT, partial brain RT, SRS boost to the resection cavity, or observation?
What adjuvant treatment should be offered after a complete resection?
Is there data related to types of metastases (tumor histology, anatomic distribution, hemorrhagic, diffuse, size, edema etc.) and risk for seizure?&nb...
Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...
Would you include the hygroma in your cavity volume? Does your decision change if you are treating a low grade vs high grade glioma? Are there other c...
Several radiation oncologists have switched from 6MV to 10MV for cranial IMRT plans to prevent alopecia. Is this theoretical or do we have data? And a...
If so, what dose?
In particular, would you offer memantine to those with WHO II or III gliomas and a good performance status but larger treatment volume?
What is an appropriate target volume for a chordoma or chondrosarcoma after a gross total resection?
Should the whole resection cavity be included?
Two randomized trials which included single-fraction post-op SRS as an arm reported high 1-year local failure. In Alliance N107C (12-20 Gy, 2 mm PTV m...
Is there concern for erythema multiforme or Steven Johnsons?
The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.
Some prefer radiation alone, while others do chemotherapy followed by RT (possibly to lower dose vs. RT alone).
If a patient has increasing FLAIR and T1 enhancing activity, should both be included in the treatment volume? What factors to you consider in making y...
There are retrospective data (i.e. PMID 15072456) that seem to associate posterior fossa location with increased risk of leptomeningeal disease a...
What are the best options to treat a patient with brain metastasis confined to the posterior fossa if the patient is young, has a favorable cancer, gr...
What is your interpretation of the recently published QUARTZ trial? Is there a population of patients that you would consider withholding radiation th...
Do you have a preference for specific steroids? Some practices may switch to prednisone during this time.
Patients with gliomas are often on d...
RTOG 0539 takes a dose painting approach for Group III to treat edema to 54Gy and lesion to 60Gy. However, this significantly increases target v...
Can the drug continue during radiation therapy or should it be discontinued at a specified time prior to initiation of radiation?
The textbook "Shaped Beam Radiosurgery" recommends MRI q 6 months x 2 years, then annually through year 5. "UpToDate" recommends annual MRIs thr...
Specifically, what factors contribute to your dose-fractionation schedule? In what circumstances (if any) would you recommend 25 Gy in 5 fractions?
Are the interim results of EF-14 (Stupp et al) practice changing?
If so, what dose should be used?
For a patient who has completed 40 hyperbaric sessions with steroids with little improvement, what other options exist?
Is it based on symptoms only? Every 3 months?
In a patient with multiple brain metastases from NSCLC, is this reasonable?
Any advice on how to safely incorporate it into our practice?
How do the number of lesions treated and histology affect your decision making?
The long term data indicating an OS and PFS benefit with the addition PCV with RT when compared to RT alone were reported in a NCI press release (http...
The most frequent argument against whole brain RT is debilitating toxicity. However, I am having a hard time finding the most evidence based data on h...
While the Duke randomized study found similar rates of control with 1mm v. 3mm margins and higher radionecrosis with 3mm, it did not look at treating ...
The literature does not seem to report on the rates of improvement of headaches.
Is heparin or warfarin routinely held prior to treatment?
While there are clearly well-defined margin guidelines for GBM (which nonetheless differ between RTOG and other groups), little has been written about...
Should an agressive attempt at resection be made? Do factors like age, KPS, MGMT status play a role in how aggressive of a push for surgery you make?
Do you feel that it must start on day 1 with RT, as strict as even 4h prior to RT (recommended by some folks for maximal “Radiosensitization&rdq...
In RTOG 9508, 4 cm was the cut-off size for WBRT followed by SRS.
In reading through the policy of one of my state's private insurance companies, I came across something with which I'm not familiar, namely treating p...
The retrospective series quote a local control rate of 85-90% at one year and the current NCCN guidelines list this as an option following surgery for...
We are in the process of implementing a BrainLab SRS program for intracranial sites. In my previous experience, all of the planning and set-up f...
I'm aware of a number of publications that suggest that after 1-2 years, the cord should be able to handle about 50% of the original tolerance dose. &...
RTOG 9802 showed a large overall survival benefit for the addition of PCV to radiotherapy in patients with "high-risk" low grade glioma (eit...
Do you really feel the failure was because people crossed over to bev at progression, or is it simply that bev does not affect overall survival?
It is my impression that for brain metastases >3 cm it may be preferable to deliver fractionated SRT versus the RTOG dose of 15 Gy SRS, if WBRT is ...
Our neurosurgeons have been pushing for definitive and postop SRS in patients with a poor performance status. Should I consider this or is it tot...
We rarely treat grade III oligos with sequential PCV and RT, despite the positive results of phase III trials. We do TMZ alone until progression which...
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